Facilitators and barriers to contraception access and use for Hispanic American adolescent women: An integrative literature review

Statement of the problem Hispanic American adolescents experience high rates of pregnancy with profound consequences. Compared with White teens, Hispanic teens use contraception less frequently and often choose less effective forms of contraception. Access to contraception is a primary barrier to use which contributes to relatively high and disparate rates of pregnancy in Hispanic teens. This integrative review identifies facilitators and barriers of contraception access and use for Hispanic women, 13–17 years of age, living in the U.S. Methodology Following the Whittemore and Knafl (2005) methodology and PRISMA guidelines, peer reviewed studies were retrieved from PUBMED, CINAHL and EMBASE. The Mixed Methods Appraisal Tool was used to assess the study quality and thematic analysis was used to categorize barriers and facilitators. Findings Of 131 studies retrieved, 16 met inclusion criteria. Individual, interpersonal and healthcare provider factors were identified as primary categories of barriers and facilitators with structural issues comprising an additional barrier category. Individual level barriers were disproportionately represented and further categorized into themes: beliefs/misconceptions, dislike of contraception, pregnancy risk perception, lack of knowledge, and lack of control. Barriers related to cultural and religious influences were identified in individual, interpersonal and structural levels. The most frequently reported facilitators were perceived parent comfort discussing sexual health and past experience of pregnancy. Discussion Limitations in this review may stem from heterogeneity in the acculturation and geography of participants and analysis by a single reviewer. Implications include considering the range of information sources and the influence they have on risk perception and risk mitigation for this population. Conclusion & significance Adolescents describe many modifiable influences on contraception access and use. Misperceptions related to contraception, stemming from beliefs and perceptions, can be corrected through increased access to reliable sources of sex education, parental support, and direct access to nurses and healthcare providers. Awareness of these influences can inform further research and intervention development to address these health disparities.


Introduction
Unintended teen pregnancy in Hispanic women is a significant public health problem that has profound consequences.Compared with White teens, Hispanic teens use less contraception with 24% of white teens and 12% of Hispanic teens reporting to have used contraception at last intercourse [1,2].When they do use contraception, the methods they use are less effective with 38% of white teens compared with 18% of Hispanic teens using prescription forms of contraception [3].Hispanic teens have described significant barriers to accessing effective contraception, which contributes to relatively high rates of teen pregnancy [1].
Hispanic teen women experience teen pregnancy at a rate of 25.3 births per 1,000 women, compared with 11.4 birth per 1,000 Non-Hispanic White women [4].In addition to being a costly problem with estimated annual healthcare costs of $6 billion in lost tax revenue and $3 billion in public expenses [5], it has significant short-and long-term consequences for teen mothers and their children [6,7].Teen pregnancy can affect educational attainment, economic status, and mental, social, and physical health for mother and child.The school dropout rate is higher for pregnant teens, which disrupts education and can subsequently limit employment possibilities, earning potential and increase risk of poverty [5].Teen mothers have an increased risk of depression, substance abuse, and criminal conviction [5].Children of teen mothers may have adverse health and developmental outcomes including prematurity, low birth weight, higher risk of perinatal and infant mortality, and poorer long term cognitive development [5].These consequences affect long-term health trajectories and disproportionately affect Hispanic adolescents and their children [8].

Disparities in contraception use and access
According to the CDC, 75% of pregnancies in women between the ages of 15-19 years are unintended [9].Unintended teen pregnancy is avoidable through abstinence or consistent use of effective contraception [10].Contraceptive misuse or nonuse [11] or use of less effective contraception [12] may be partially explained by lack of knowledge about pregnancy risk, birth control, barriers to access, or distrust of the healthcare system [12][13][14].The most effective methods of contraception for sexually active teens, such as oral contraceptive pills, intrauterine devices, and contraceptive implants, require a prescription [10,13].
Healthcare access is defined as "the timely use of personal health services to achieve the best health outcomes" [15].The Institute of Medicine definition of 'access' combines it with healthcare use, which can be considered "realised access" [16].Identified barriers to contraception access include affordability, shame, embarrassment and physical difficulty reaching services and these barriers disproportionately effect individuals from marginalized populations based on age, income, race/ethnicity, rurality, and education [17].In contrast, expanded access to family planning services has been shown to increase use of contraception and reduce teen pregnancy rates [10,13].However, adolescents may have little experience and fewer resources to access care and are less likely to receive adequate care when they receive services [12,18].
Despite the myriad of known barriers to contraception access, three out of four teens are successfully finding and using contraception [1] which raises questions about the factors that determine contraception access and use and how some women are able to access contraception while others are not.

Definitions
This integrative review was conducted to identify literature related to the access and use of contraception among female Hispanic adolescents or teens, living in the U.S. The World Health Organization defines 'adolescence' within the age range of 10-19 years [19]; however, for this study we used a narrower age range of 13-17 years old because of the high rates of inconsistent contraceptive use and unintended pregnancy in this group [20].'Hispanic' is defined as "a person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race" [21].Given that Hispanic is an ethnic identity, individuals who identify as Hispanic may pertain to several distinct racial groups, the majority of whom identify as multiracial [22].'Contraception' is defined as the "intentional prevention of conception through the use of various devices, sexual practices, chemicals, drugs, or surgical procedures" [23].While abstinence is included in the definition of contraception, for this review, our interest is in sexually active teens accessing contraception.

Study search
This integrative review follows the Whittemore and Knafl [24] methodology which is a fivestep process that identifies the problem, conducts a well-defined literature search, assesses study quality, analyzes data, and articulates conclusions.The Mixed Methods Appraisal Tool, Version 2018 (MMAT) [25], was used to assess the quality of included studies.The data from primary sources was extracted into tables and categorized, synthesized, and summarized into integrated conclusions.
Eligibility criteria.Inclusion criteria for this review were studies published in English, in peer reviewed journals, prior to February 2024 that addressed female Hispanic adolescent access to contraception or birth control.Studies were included when the sample included Hispanic adolescent women between the ages 13-17 years of age living in the United States.Studies were selected based on meeting the inclusion criteria and non-Hispanic groups, males and multiple age groups were included if data was presented separated by race/ethnicity (Hispanic), gender (female), and age (13-17 years old).
Studies were excluded if they were not peer reviewed, gray literature, non-English studies, and studies that were not related to the research questions such as intervention studies, healthcare provider strategies or studies about parental views of contraception.Intervention studies were excluded because the purpose of this review is to identify naturally occurring strategies reported by adolescents that facilitate access to contraception.
Selection process.Once the search was completed, duplicate studies were removed, titles and abstracts were screened for eligibility, and full texts were then reviewed for inclusion including relevance to the study aims.Excluded studies were grouped by reason for exclusion as noted on the PRISMA flow diagram (Fig 1) [26].The initial search resulted in 131 studies, of which 16 were included in this integrative review.
Quality appraisal.The MMAT [25] is a critical appraisal tool designed for reviews that include qualitative, quantitative, and mixed methods studies [25].This tool facilitates the process of appraising various types of literature in one tool by answering the series of quality assessment questions as they are presented rather than calculating an overall score [25].
Data extraction and synthesis.Following the process outlined by Whittemore and Knafl [24], data were extracted from the 16 selected articles including sample characteristics, location, study design, theory used, measurement tools, outcomes, barriers, and facilitators.These characteristics were determined by the author (LB) as useful for answering the research question.Barriers and facilitators were identified by reviewing the data and placed on a spreadsheet.As each study was read, the barriers and facilitators cited in that study were added to a spreadsheet, and as the items listed increased in number, the items that shared similarities were iteratively organized and grouped together into subthemes.As the analysis continued, many subthemes had developed, and they were organized and grouped into themes and later categories [27].Each occurrence of a barrier or facilitator in the 16 selected studies was counted, and the total frequencies across all papers were tabulated and organized into tables and figures.

Study selection
Of the 131 articles identified from the database search, 31 duplicates were removed, 100 articles were screened by their title and abstract, 46 of which were excluded because they were off topic.The retrieval of full text was sought for 54 records.Full text articles were unavailable for 8 articles, and 46 were screened.Reasons for exclusion are noted on the PRISMA [26] flow diagram.The remaining 16 articles were included in the review.

Study methodology
This review was based on 16 peer reviewed articles published about barriers and facilitators to contraception in Hispanic adolescent women living in the U.S.This review included qualitative studies (n = 11), quantitative descriptive studies (n = 3), and mixed method studies (n = 2).For the qualitative studies, the type of qualitative methodology (grounded theory or ethnography, etc.) was rarely described.Qualitative studies relied mostly on interviews [28][29][30][31][32][33][34] and focus groups [8,11,18,31,35].Barral et al. [6] used mixed methods and grounded theory focus groups and open-ended questions.Gilliam et al. [1] used focus groups to develop a survey instrument to later give to participants.For the quantitative studies included in this review, there were very few validated scales or measurement tools that were used to measure the outcomes of interest.Of the few quantitative studies that used survey instruments, measures used included the contraceptive failure rate (CFR); contraceptive risk indices (CRI), which represents pregnancy risk; and the pregnancy risk index (PRI), which is the probability of pregnancy based on sexual activity and birth control method [2].Two studies were secondary analyses [2,36] and one was a retrospective chart review [13].

Study quality
The aim and purpose of the studies were well-aligned with the research questions, chosen methodology and interpretation of the data.The MMAT indicated that the selected studies were generally of high quality with low risk of bias although a few weaknesses were apparent, such as use of a convenience sample, conceptual issues such as grouping belief and experiences together, not explicitly stating the validity of the measures used, and a lack of information about non-responders.The results of the quality assessment are listed on the third column of Table 1.

Study characteristics
Study size and geography.The sample size in the studies ranged from small (n = 8) in the qualitative studies, to large, the National Survey of Family Growth, N = 9321.One study had focus groups from Mexico and California [31] and all of the remaining studies took place in the U.S. in both rural [6,34] and urban areas [1,11,35].Some studies described the state or city locations, with represented regions in the U.S. including the East Coast (Baltimore [35]); Midwest (Kansas [6], Chicago [1,11]); the South (Alabama [32], North Carolina [34]); and the West Coast (California [31]).
Acculturation.The acculturation level of the participants was inconsistently provided.Some studies describe the acculturation level of participants in the results [1,6,28,31,33].When acculturation was described, it was by place of birth [30,32,34,35], length of time in the U.S. [32], or acculturation score which was determined by a language based scale [1,33] or a modified version of the Short Acculturation Scale for Hispanics (SASH) combined with years living in the US [6].
Theoretical frameworks.Some studies articulated a theory that guided their research such as the Theory of Planned Behavior [34,35], the Health Belief Model [29], the Socioecological Model of Sexual Health [32], Pechansky and Thomas' Theory of Access [31], and the Construct Accessibility Model [33].

Facilitators and barriers to contraception described by category
Through the data extraction and synthesis process, both the facilitators and barriers were grouped into the following overarching categories: individual, interpersonal (family, spouse/ partner, friend), and healthcare provider levels; further, contextual matters emerged as an additional category of barriers.Each of these main categories was further subdivided into thematic subcategories as displayed in two sunburst charts, one for facilitators (Fig 2 ), and one for barriers (Fig 3).On both charts, the categories that resulted from the thematic analysis are visible in concentric rings with themes in the center and related subthemes on the periphery.The sizes of the parcels in each chart are proportional to the number of occurrences of that barrier or facilitator category across the 16 selected studies.
The individual level barriers constituted a disproportional amount of the total barriers identified in this review with the number of data points nearly triple that of any other category.Individual barriers to contraception access were divided into five subthemes.The subthemes include beliefs/misconceptions, dislike of contraception, pregnancy risk perception, lack of knowledge, and lack of control.Specific factors that were most frequently described as barriers The interviews suggest that for these young mothers, it was not really sex that was being negotiated, but the couple's entire relationship."Rational" decision making regarding sex, contraception, and STD prevention could only become the norm for these young couples after they had been having intercourse for some time.
The third theme, 'pregnancy risk perception,' encompasses several attitudes and beliefs, including the view that there is no risk of pregnancy [18,28,31], avoidance of condoms, perceiving them as protection against sexually transmitted infections rather than for pregnancy prevention [33], and ambiguous or actual desire for children [6,11,28,29,34].
Lack of knowledge and lack of control were the final two subthemes in this category.Participants described a lack of information about contraceptive options [11,28,[30][31][32][33][34][35], feelings of embarrassment, stigma or lack of confidence accessing care [32,34], and a lack of knowledge about biology and physiology [30].Lack of control related to male partner dominance [11,29,30,35], reliance on the male partner for the withdrawal method [11], lack of control over pregnancy related to infertility beliefs, religious influence and feelings of invincibility [11,18,28], uncertainty about the future [29], unplanned or unexpected intercourse [30,34], and not considering condom use [33].

Category 2: Interpersonal level facilitators and barriers
Interpersonal facilitators to contraception access included parent comfort in discussing sexual health [8,32,34], accompaniment and transportation to the doctor [32,34], positive reinforcement from family, friends and schools [1,8,31,35], mother/daughter alignment or parent support on sexual and reproductive health (SRH) [8,32,34], friends who have had positive experiences with contraception [29,31], and mutual agreement with partners about not wanting a pregnancy [29].
Guilamo-Ramos et al. [8] and Morales-Alema ´n et al. [32] explored the vital role of the maternal and parent influence on the daughter's SRH.The need for support was expressed by several teens "My mother doesn't really understand . ... If only my mom could get it and understand I could really use her support."[8].And ". ..I pretend I have never done it.That way, I can avoid a fight."[8].Morales-Alema ´n et al. [32] reported that the main barrier to accessing SRH services for most participants was parental disapproval of them having sex and using these services.While some mothers were supportive and proactive in pregnancy prevention for their teens, others were unsure, as one parent expressed, "Should I mention it?It's really confusing and scary because there is so much I do not know.Nobody ever told me.I got pregnant early on."[8].These experiences reflect how the maternal influence can be either a facilitator or barrier to SRH uptake.

Category 3: Healthcare provider barriers and facilitators
Characteristics of healthcare providers that facilitated access to contraception included patient-centered communication, nonjudgmental and non-discriminating interactions, and trustworthiness [29,35].Clinic features that facilitate access were providing privacy [18], having respectful office staff [29,30], and being located in a school-based health clinic [29].Healthcare provider barriers were low patient-rated communication [35], perceived discrimination [18,32,35], or inadequate care given due to race [35].

Category 4: Structural level barriers to contraception
Structural level influences on contraception were described in studies only as barriers (no facilitators were described) to contraception and categorized into cultural and religious, geographical, and practical influences.Cultural and religious influences identified included, sexual taboo or stigma [11,30,32,33,39], placing a high value on virginity [6,30], valuing sexual ignorance and sexual passivity in women [30] and religious objections to the use of contraception [1,35].One study by Carvajal et al. [35] described contradictory findings regarding the influence of religious ideology and norms.Norris & Ford [33] report a specific stigma found in their study: the perception that condoms are for unclean people.A geographic barrier to contraception access was neighborhood contexts that influence younger sexual initiation [2].Practical matters that were barriers to contraception were loss of Medicaid and continuity of care (related to the end of pregnancy) [34], lack of time for a clinic visit [32], lack of public transit or transportation [29,32], lack of insurance and cost [11,32,34], and need for interpreters [32] and concerns about documentation status or immigration [40].Additionally, two studies reported that participants mentioned the negative influence of media and internet advertisements about contraception as inducing fear [18,29].

Discussion
This analysis sought to better understand barriers and facilitators that influence access to and use of contraception in female Hispanic teens ages 13-17 years old.Sixteen studies were included, and 40 specific barriers and 16 facilitators were found and presented as subthemes.The facilitators that emerged from this analysis provide insight into potentially outcomechanging influences that support women's reproductive autonomy, decision making, and acquisition of contraception.
Culture and religion are structural barriers that were also present as barriers in the interpersonal and individual levels.This separation was maintained to preserve the integrity of how they were experienced and expressed by women in the different studies.For example, on the individual level, stigma and taboo and various beliefs were barriers to contraception as well as on the interpersonal level, the familial influences of familismo, family dishonor and family beliefs that prohibit birth control appear to be all related to the cultural and religious ideology.How these influences are experienced by the women who voiced these barriers in the included studies may be important to inform the creative solutions that will be needed to address these unique barriers that permeate multiple levels.Sentiments such as "abortion is murder" or that contraception is equivalent to abortion [6,28], and the belief that withdrawal will work if pregnancy is not desired [11] illustrate how ideology can intertwine with misconceptions leading to inaccurate perceptions about risk and risk management.These views, combined with barriers such as embarrassment, stigma and lack of confidence accessing care [32,34] and lack of knowledge about biology and physiology [30], highlight the complex influences that make it challenging for teens to seek information and ask questions from reliable sources such as trusted adults and healthcare providers.This complexity can contribute to a sense of lack of control, exacerbated by male partner dominance (with age difference) [11,29,30,35] and reliance on the male partner for the withdrawal method [11], and a lack of control over pregnancy due to beliefs about fertility, religious influences, and feelings of invincibility or the perception that 'it won't happen to me' [11,18,28].Interventions that inadequately address these barriers in meaningful ways may be less effective or ineffective.
In contrast, key facilitators include a clear intention to avoid pregnancy, parental comfort discussing sexual health, positive reinforcement from family, friends and school, and good communication and trust and respect from healthcare provider and their office staff.These are actionable items that warrant consideration in the development of future interventions.

Implications
When considering how an individual makes decisions regarding contraception, perception and understanding of risk and ease of mitigating risk are each important.This review demonstrated the different sources of influence ranging from individual beliefs to personal experience of pregnancy, to people who directly support and influence teens such as parents, peers, partners, and healthcare providers as well as structural influences that limit information or access.

The role of education
Misconceptions and lack of knowledge about sexual and reproductive health were frequently mentioned as barriers and are important factors in how teens make choices about their SRH.The misconceptions and lack of knowledge may be remedied through education either through sex education classes in schools in the U.S., or through education received from their families, peers, partners or their health care providers.Yet, there may be barriers to each of these information streams.Hispanic students may receive less school-based sex education because they are more likely to drop out of school [41] or move frequently, which may preclude them from receiving adequate sex education [6].Even when Hispanic students receive sex education in school, the quality and content provided is inconsistent ranging from abstinence-only to comprehensive sex education leading to disparities in what is learned, and related outcomes [42].Parents, peers, partners, can have a strong influence on information about contraception and contraception access and can serve as barriers or facilitators.Morales-Alema ´n's et al. [32] finding that parent disapproval of teens having sex was their main barrier to access to care for SRH, which indicates the importance of parent attitudes towards teen access to contraception as either a barrier [11,32,34] or facilitator [32].Male partners can be barriers through male partner dominance and controlling withdrawal or facilitators through mutual agreement with partner about pregnancy intentions, positive reinforcement, providing contraception or supporting access to the healthcare providers.Healthcare providers are positioned to prime parents to be supportive of teen's access to care for SRH.They can also support teens independently by providing care that is private, confidential, nonjudgmental, non-discriminatory, and patient-centered and in an accessible location.

Structural considerations
While providing correct information through reliable education sources may serve as an important facilitator to contraception access, the role of structural influences is fundamentally important to keep in mind.No structural level facilitators were identified, but some key facilitators from other levels were identified in this review that may counter the barriers that can come from the structural level.On the interpersonal level, mother/daughter alignment about contraception, and supportive peers and partners were important and on the individual level more communication about contraception was an important facilitator.And regarding practical matters, providing supports such as transportation, translators, and insurance assistance may help.Awareness and inclusion of these supportive influences are valuable considerations when designing interventions to promote access to contraception for this group.
Further research can build upon the findings presented here by discerning what meaningfully differentiates those who have adequate awareness of pregnancy risk and the ability to access contraception from those who do not.This may reveal the relative impact of different factors on teens, how these factors synergize to serve as barriers or facilitators, and patterns in how these influences affect teen contraceptive access and use.Understanding these dynamics may identify targeted strategies to reduce disparities in teen pregnancy.

Limitations
The studies included in this analysis grouped teens by the umbrella terms of 'Hispanic' or 'Latina' but there is considerable diversity and variation within this group.Though commonalities such as taboos, stigma, and misconceptions were found, it is unclear if more research across ethnic or national subgroups may reveal important differences.The presence of bias in the findings presented in this review cannot be ruled out as a single author [LB] conducted the literature search, assessed studies for inclusion, rated bias, extracted, analyzed, and synthesized the data.The search sought to identify studies about Hispanic teens but did not search all potential places of origin of Hispanics in the U.S. such as Mexican, Guatemalan, Puerto Rican, Columbian etc., so studies about those specific groups, while applicable, may not have been identified.

Conclusion
This integrative review sheds light on the barriers and facilitators to contraceptive access from the perspective of female Hispanic teens, aged 13-17 in the U.S. The synthesis of perspectives and experiences revealed in this review is informative and significant, given the disparities in contraception access and pregnancy rates in this group.Identification of barriers and facilitators can stimulate discussion and research aimed at improving the delivery of education and healthcare to meet the contraceptive needs of female Hispanic teens.The implications presented here underscore the importance of addressing the barriers and leveraging facilitators encountered by this population to promote health equity and improve access to contraception.

Fig 2 .
Fig 2. Facilitators to contraception.Themes identified as facilitators to contraception use are displayed in the inner circle and are further differentiated into the subthemes located on the outer circle.https://doi.org/10.1371/journal.pgph.0003169.g002

Fig 3 .
Fig 3. Barriers to contraception.Themes identified as barriers to contraception use are displayed on the inner ring by with subthemes located on the outer ring.https://doi.org/10.1371/journal.pgph.0003169.g003